Tungba was a large, muscular male black lab that I met shortly before I went to veterinary school. His owner, Mark, was the brother of a good friend of mine. Mark was a few years older than me, and was a man of great compassion. He was a minister of a congregation in the roughest section of Baltimore city. He introduced me to the organization Habitat for Humanity. He and his flock were transforming the community around them.
Mark and Tungba were a great team.
They provided refuge for children of drug-addicted parents. They gave hope to those who had none.
Mark looked a lot like John Lennon, with his round glasses and thin build. Not only was Mark a contemporary of mine who was making a difference, but he loved his dog. He was an inspiration to me as I started my career.
Tungba was present when Mark's sister was married in Maine. They drove up from Baltimore in Mark's old Honda with the hatchback set up for Tungba. He had a wool blanket, a water bowl , 2 tennis balls and a chew toy. I have a strong memory of Mark the next day standing by the bank of Moosehead, throwing a stick. Tungba would splash in, and come out with the huge branch in his mouth, dripping with lake water. To prevent ruined wedding dresses, Tungba obediently stayed in the cabin during the actual ceremony.
When I was in my first practice in Annapolis, Maryland I got a call from Mark. Tungba had been feeling poorly and not eating. Those of you with a lab know, refusing to eat is unusual to say the least. He felt a lump on his back leg. Since he was about an hour away I encouraged him to get it checked at a practice nearby and call me after he had been seen.
The next afternoon Mark called me back. He sounded anxious. The vet had felt several enlarged lymph nodes, and had scheduled a biopsy for the next day. He checked his calcium and it was elevated, a sign of a lymph node cancer called lymphoma.
When the biopsy came back it was a high grade lymphoma. Mark told the vet he wanted to talk to me about it before he made any decisions. I explained to him that although high grade lymphoma was a bad disease, it was a type of cancer that was very amenable to chemotherapy. With no treatment at all, Tungba could be expected to live weeks to a few months. With a common chemo protocol, he would have a 90% likelihood of going into remission, or have the cancer go away for awhile. He would have a 50% likelihood to be alive in a year. Each case was different, but statistically, lymphoma was pretty responsive to chemotherapy.
He asked me questions.
Would Tungba get sick from the chemo?
In most cases , no. Dog's tolerance for chemo drugs is much higher. They do not lose their hair and the primary side effect is nausea which can be treated with new effective antiemetics. Tungba's white blood cells would have to be monitored after the treatment to ensure that the count did not get below the level that would protect him from other infectious diseases such as pneumonia.
What was my experience?
I had only worked at that point in my career with 3 dogs that had lymphoma treated with chemotherapy. One did not do well, the others were still alive.
How much would it cost?
At the time the cost with testing and chemo was around $2000, the chemo would go on for months, and costs could increase if there were problems.
What would I do if Tungba were mine?
This is always a difficult question for me, but I always strive to give my honest opinion, hoping that the owners will not be too swayed by it. I told him that I would do it. Tungba was 8 years old, in otherwise good health. He was a huge part of Mark's life and chemo was probably going to give him longer. In the best scenario, he could live years and years.
Are there other alternatives?
Prednisone can be used to make them feel better and sometimes put them into remission. However, if we do Prednisone for more than 2 weeks, it will lessen his response to chemo. In addition, low carbohydrate diets have been shown to slow down lymphoma, as has omega 3 fatty acids in large doses. Other alternative therapies are available and I could send him to someone who could speak to that better.
He thanked me and told me he would call back when he had time to digest it.
The next week he called me back to tell me that he wasn't going to treat Tungba with chemo, but give him his comfortable time and put him to sleep when it was time. When I asked him why, he said something that caught me off guard, but has come back to me countless times since then.
He said that every day he worked with people, especially children who had no resources, little food and little chance of breaking out of the cycle of poverty. He told me that he could not look those kids in the eye and tell them that he had spent $2000 on chemo to prolong his dog's life.
Two years ago a colleague that I respect a lot had a 7 year old lab with Lymphoma. She gave him chemo, he went into remission and then came out quickly. With research she found a program at the University of North Carolina Veterinary Oncology department where they did a complete bone marrow transplant to treat the cancer. First he had to be irradiated to destroy his bone marrow. Then he was given new bone marrow and they waited anxiously for the response. In the meantime he was kept in quarantine to keep him from contracting a contagious disease in his immunologically compromised condition. He was the 19th patient for their program. He is still doing well today.
Ethical dilemmas are seldom absolute. What is right and wrong changes somewhat with situation and with time. There are some questions that most people would say yes or no to, but the bulk of what we struggle with as humans is not quite so black and white. I totally understand both decisions.
Tungba lived for about 6 weeks and when he got sick he let his friend go.
Today I'm grateful I haven't had to make a decision like this in my own pets. I have had to put several of my own to sleep, and there has been times as well upon looking back that I think that I have waited too long. But as technology increases, what we can do to help our pets increases as well.
I recently spoke to the daughter of a great client of mine who lived in another state. She had a young cat who presented to an emergency clinic with difficulty breathing. Xrays and bloodwork did not confirm the diagnosis, but the Xray was suspicious of a heart problem. The cat was miserable outside of oxygen and the emergency clinic, her regular vet and the specialist they recommended were all closed the next day. No one had taken the time to tell her that the most likely thing in the heart was a disease called hypertrophic cardiomyopathy. With intense treatment, this can be stabilized in some cats. But with a cat that started with severe difficulty breathing, the trek was going to be uphill to say the least. This cat was not a daily-medication-stay-in-the-hospital kind of cat.
As a profession, we don't always spend enough time communicating the basics, especially if it is potentially bad news. I believe that sometimes looking you in the eye and telling you the bad news is necessary so that you can make good decisions going forward. I no longer focus on what is the right thing to do, because that depends on the situation, the timing and the pet. My job is to lay it all out on the table, and together we will work out the right thing to do.
We face a time in veterinary medicine where the technology is growing exponentially. Our true goal as veterinarians should be to use that in the framework of the relationship between pet and human, as well as common sense, to come up with the best solution. Communication during the process is critical. I wrote about the specialist being a gift a few emails back, and that they can be. But just as important is having a primary relationship with someone who can help you navigate the waters. This is a huge challenge on the human medicine side...we've all heard stories of the ethical horizon being lost in care of people. There are more specialists, more paperwork, more third party oversight.
The story of Tungba and Mark for me represents that to know what is right for the patient and client, you have to listen to the patient and client. Until I get that Dr. Dolittle thing going, I have to rely on you, the client, to tell me how you feel about the next step. Know that your answer may require some time as you weigh your options. Know that we are doing this is as a team...a team of Kindred Spirits.
